Practitioner Medicare billing edits change effective June 1

Currently, if a provider bills multiple units on single or multiple lines of a claim form and the total units for the CPT code exceed the Medically Unlikely Edits (MUE) limit, Priority Health may partially pay the claim line(s) up to the allowed units, depending on how the provider billed.

Effective June 1, 2018, clinical edits to practitioner claims will align with criteria defined by the MUE adjudication indicator (MAI). If the total units for a code exceeds the MUE limit, then all units will be denied instead of a partial payment being made.

About the MAI

The MUE program was established by the Centers for Medicare and Medicaid Services (CMS) to reduce the Medicare Part B paid claims error rate. Additional specific information about the MAI can be found in the CMS Manual one-time notice, Revised Modification to the Medically Unlikely Edit Program, from 2015. Here is a summary from that document:

At the onset or implementation of the MUE Program, regarding the adjudication process, the MUE value for a Healthcare Common Procedural Coding System (HCPCS) code was only adjudicated against the units of service (UOS) reported on each line of a claim. On April 1, 2013, CMS modified the MUE program so that some MUE values would be date of service edits rather than claim line edits. Therefore, at that time, CMS is introduced a new data field to the MUE edit table termed “MUE adjudication indicator” or “MAI”. CMS is currently assigning a MAI to each HCPCS code.